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Medical practitioners often do not advocate for the new systems because they were not involved in the design. This design development model is decoupled from practice and has traditionally focused on the design of larger scale technology systems: life monitors, infusion devices and imaging technology. From the side of the medical equipment manufacturers, design strategies behind these devices address the hospital administration as customer and often not the needs of the medical practitioners because they do not make purchase decisions.

Regulatory expense and complexity in health care are also hurdles to creating innovative devices or iterative improvements to existing ones.

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The industry-driven and technology-centered design and development approach for medical equipment makes it difficult for medical practitioners to become involved in early design stages where they could provide insight and critical input into what products should be developed. The model also falls short in examining the potential of design innovation for smaller scale design projects that address issues that emerge in day-to-day medical practice.

The issue that the present case study addresses had surfaced in , when a series of medication handling incidents in a number of hospitals initiated a wave of internal medication handling safety evaluations at various hospitals around the world. The analysis of findings from their observations in the operating room and conversations with colleagues about anesthesia practices was driven by the hypothesis that vulnerabilities exist in current anesthesia medication management practice and that aspects in the routine work flow could be improved by integrating new forms of structure, thus making the work more observable and deviations more easily detected.

Omission or swap errors would stand out so that they would be noticed before they could cause harm. One goal of this process was to identify leverage points for design intervention—areas where minimal change would yield significant positive impact. In contrast to the large-scale projects initiated by medical suppliers from the outside, this was a design opportunity that was discovered by medical practitioners who had critically examined their own work practices, work environment and the organizational structure that had governed operations.

The framing of the design opportunity at the time as a new form of structure that would guide medication handling pointed to a small-scale design intervention that that could be developed from within the medical work setting.

The composition of our design team with physicians and designers was crucial to the success of the design. Design through the lens of the practitioners was possible because the design of the AMT was initiated by anesthesiologists who had conducted the internal medication handling safety study. The physicians had championed the design project through the hospital organization and due to their organizational status as key expert practitioners, they were able to generate broad support to create a unique design environment that provided the design team with access to examine key aspects of anesthesia practice.

We had previously collaborated on a successful medical design project Grigg et al. There was strong advocacy for design on the side of the medical experts in our team and there was expertise in the design for high-stakes environments in aviation, medicine and process control on the side of the designers who had secondary backgrounds in Cognitive Systems Engineering that complemented their Industrial Design expertise.

The physicians on our design team contributed their expertise in anesthesia practice to the design task. They pointed the designers to interesting aspects in existing workflows, were able to detect nuances during observation that would go unnoticed by the designers and would reach out to the appropriate experts in their organization to address design questions.

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The anesthesiologists were the insiders of the processes under the design lens. The outsider perspective of the designers helped the practitioners to reveal previously unnoticed design opportunities in their practice by connecting the design work at hand with similar design situations in aviation and process control where design had provided cognitive support. Applying a practice-centered design approach, our aim was to support ongoing practice in the work setting with the intent to support practitioners in what they are doing best.

In terms of the expertise and design techniques that the designers contributed to the team, the AMT was developed by a combination of Industrial Design, Interaction Design and Visual Communication Design techniques. Table 1 illustrates how the different types of design expertise were combined and distributed to address the design requirements for the AMT that we encountered during the process.

Design decisions were based on observations of practice in the medical work setting, direct design input from and co-design with practitioners, iterative development, testing and evaluation of the design in the work setting, and the application of best practices in design from similar high-stakes domains in aviation and process control. Table 1. Design constraints, considerations and relevant design expertise areas for the design of the AMT.

During this first stage of the design project, our team began to examine anesthesia medication workflows to identify promising areas for design improvement. We studied the arrangement and use of medications on the anesthesia cart in the operating room. The anesthesia cart contains all medication preparation supplies and pre-drawn medication syringes for the anesthesiologist. In addition to airway management, the course of an anesthetic is largely determined by a carefully orchestrated sequence of medications, many of which have profound physiologic consequences and must be precisely dosed.

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This occurs in a dynamic and fast-paced operating room setting where there are often distractions and concurrent tasks for the anesthesia provider to perform. Before and during an anesthetic, providers prepare medications in plastic syringes that are arranged on top of the anesthesia cart. Currently, the manner in which providers organize and interact with medications on the anesthesia cart top is highly variable across institutions Figure 1 and lacks visual design organization and rigorous input from human factors and interaction design.

Figure 1. Different medication arrangements on the anesthesia cart captured during field observation. In the absence of a layout, anesthesiologists have developed their own medication arrangement schemes. These arrangements were handed down from the different medical schools, training and practice sites or are the result of personal work style. These observations revealed variation in arrangement schemes and it became clear that developing a standard organizational structure for syringe arrangements on the cart top would be a promising design opportunity.

The historic anesthesia cart and medication syringes are the result of unconnected industrial design efforts. The arrangement of the anesthesiologist and the patient, as well as the arrangement of the anesthesia cart and life monitor have been a standard in surgical practice for more than forty years Drui et al.

Some syringes will be used only once; others will be used multiple times throughout a case; still others sit largely unused over the course of a day of multiple cases and are only there in case of emergency. Syringes come in multiple sizes and are typically adorned with color-coded labels. The consequences of selecting the wrong syringe can be severe. The design hypothesis was that a standardized medication layout on top of the anesthesia cart could reduce medication mix-ups and omissions. This design hypothesis helped to frame subsequent field observations in the operating room.

The design project for the AMT was initiated. The team began to examine the anesthesia workplace as a fast paced and high stakes interaction setting with the intent to improve workflows by providing cognitive support for the appropriate selection of medications to reduce medication mix-up errors.

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In the course of the following three years, the design and refinement of the AMT cycled through observation, ideation and realization in a quest for obtaining fit between design possibility and existing context. This process is a concurrent design activity that converges three types of expertise: expertise as practitioner in the field under design, expertise in design and expertise in product realization and integration into the field of work Roesler et al. Figure 2 provides an overview of the different stages in the design process.

Figure 2. Call-outs refer to the various design stages described in the following. The design of the AMT was developed by carefully analyzing the interactions between anesthesiologists, anesthesia medications, anesthesia cart and patient. These interactions would frame the use of the AMT and in turn shape its physical layout for the arrangement of medications. To test different layout concepts, a series of PowerPoint layout drafts were printed and laminated to serve as syringe arrangement templates at full scale.

These layout sheets allowed the physicians to experiment with syringe arrangements on the cart top in an authentic work setting configuration in terms of height, viewing distance and lighting conditions. They were able to determine basic field arrangements, order and field sizes to accommodate the different size syringes. The early prototypes were used to facilitate feedback from other anesthesiologists. This stage of design benefitted greatly from the inside perspective of the anesthesiologists—leading to insights that were grounded in the culture of the work setting, encompassing social roles, tacit knowledge, individual preferences, personal styles and expertise in anesthesia.

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The prototypes facilitated conversations about the design as knowledge exchange between colleagues rather than a collision of insider knowledge and outsider insights that is typical when external design teams present to practitioners. Because the design project was owned by the practitioners internally, the design team was able to connect with other practitioners in the work setting, often impromptu and informally. This resulted in fast and direct feedback gathering based on existing relationships in the work setting that was grounded in professional respect and mutual trust.

Insights included approaches to learn and modify distinct workflows and strategies to provide support structures for critical situations in the workflow. Table 2. Interaction design constraints and design considerations. In a progression of several prototypes, the team designed layouts to record their understanding of medication arrangement patterns that would be favored by individual practitioners, then the team extracted common patterns they had observed in various individual layouts Figure 1 to develop a generalized template. The greatest challenge in this layout design effort was to make the simplest design possible to be most effective.

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Observations of typical workflows revealed that less visual clutter would result in a more reliable organization system. The team realized that in order to make the design widely applicable, they would have to provide free space so that this space could be used flexibly. Early prototypes included dedicated fields for a variety of medications, many of which were commonly used. This change of design requirements and constraints would have been difficult to push for an external design team, but because of their embedding in the work setting, the physicians had a clear case to make the design call for the simplified layout that is key to the final design concept.

Half of the real estate on the template is free space to be used for medication preparation or any syringes with medications not identified in the dedicated fields. This provides anesthesiologists with adaptive space to create individual arrangements for low-risk medications. Future iterations intentionally removed additional fields for commonly used medications that are seldom problematic. Propofol, for example, is used in almost every case, but because of its distinctive white color and relatively safe side effect profile when used by an anesthesiologist, it does not require a dedicated space.

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Similarly, most anti-nausea medications do not need dedicated spaces because the likelihood and consequences of medication errors with them is relatively small. Conversely, high-risk medications including muscle relaxants, vasopressors and opioid medications as identified by the institute for safe medication practices Institute for Safe Medication Practices, were designated a specific location on the template to sequester and standardize their location within the anesthesia workspace. Figure 4 shows the medication template design that would form the basis for the visual design detail work that followed.

Based on the identified layout requirements Figure 3 , the team developed the first detailed visual design concepts of the template Figure 4 with defined typography, line attributes, use of color and balanced visual layout of the medication arrangement fields. The design also took into account the presence, sizes and orientation of the 3-dimensional syringes on the cart top in relationship to the 2-dimensional layout template to optimize identification of color-coding and readability of medication labels Figure 6. The detailed visual design defines the formal aspects of the template in order to create the desired hierarchical presentation of information to support decision-making.

Table 3. Visual communication design constraints and design considerations. Figure 3. Figure 4.